Compliance Specialist – Regulatory Affairs

Role Overview

• Research and interpret complex policies regarding government programs requirements and maintain tracking of all delegation oversight activities from contracted delegated health plans, entities and vendors.
• Coordinate strategic communications and audits with delegated entities and internal business departments.
• Manage assigned health plan audits. Independently execute special assignments with general supervision. Monitor oversight and assist in ensuring compliance to regulatory standards and health plan contracts. Apply critical thinking and problem-solving skills to all actions.
• Track and trend areas of compliance and regulatory vulnerability and risk within the organization and assist in developing solutions to enhance processes. Assist Compliance Leadership in developing and coordinating compliance training materials for the company.
• Coordinates the preparation and completion of compliance program materials, documents, presentations, and department activities with a focus on auditing and monitoring processes.
• Analyze and interpret health plan audits instructions, requests and results, and distribute to operational departments. Use critical judgment to work on developing improvement plans as it pertains to Medicare, Medicaid, Commercial, and Duals program corrective actions.
• Assist in tracking audit submissions and maintaining internal documentation for consistency. Work collaboratively with all departments to follow up on audit items and ensure accuracy of information provided and timely submission, as needed.
• Works on ad hoc projects, routine assignments, and recurring tasks under the direction of Compliance leadership. Assist Compliance Leadership in documenting and analyzing changes across departmental policies when modifications are required due to audit findings and/or regulatory changes. Communicate required changes with business leads and ensure timely compliance with changes.
• Assist with drafting new policies and updating existing policies as required to ensure regulatory compliance, identifying areas of risk and recommending improvements.
• Assist in the design and execution of internal audits to assess the effectiveness of compliance controls and operational processes.
• Helps to identify complex problems and review related information to evaluate options and implement solutions.
• Ensure data accuracy and integrity through periodic audits and continuous monitoring.
• Assists in compiling data, analyzing, and producing quarterly and monthly reports.
• Supports maintenance of peripheral databases that support Corporate Compliance reporting needs.
• Performs periodic audits to ensure the accuracy and integrity of the data.
• Manage time efficiently to meet expected deadlines and maintain productivity in compliance and audit activities.

Requirements

• 3+ years of related experience in managed care or compliance, with a strong focus on auditing and monitoring, preferably within IPA and healthcare industry.
• Experience with interpreting and applying complex Medicaid and Medicare regulations and policies in healthcare administration setting.
• Excellent oral and written communication skills, with the ability to articulate audit findings and compliance recommendations clearly.
• Strong reasoning, problem-solving, project management, attention to detail and organization skills.
• Ability to multi-task and prioritize work matters.
• Ability to work with and maintain confidential information.
• Strong interpersonal skills.
• Strategic thinking skills to provide practical advice with an awareness of legal risks in the business context.
• Intermediate proficiency in MS Word, PowerPoint, Outlook, and Excel, with a capability to utilize these tools for auditing and compliance reporting.

Benefits

• This is a primarily remote position where the expectation is to work at home. You will be required to be onsite as needed (~few times per month). The home office is located at 600 City Parkway West 10th Floor, Orange, CA 92868.
• The national target pay for this role is $70,304.00 to $83,865.00 per year. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.
• Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need.